Connecting Virtual Reality and Occupation Robert C

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Connecting Virtual Reality and Occupation Robert C. Ferguson, MHS, OTRL [email protected] Michael Blackstock, MS, OTRL [email protected]

1 Objectives

• 1) interpret the current research on the therapeutic use of immersive virtual reality in rehabilitation. • 2) analyze the capacity of different immersive virtual reality platforms and activities in order to facilitate a patient’s performance skills and treatment goals. • 3) integrate immersive virtual reality technologies with evidence- based treatment strategies and techniques to enhance their practice.

2 The Virtual Context and The Reality - Virtuality Continuum

3 The Tangible and Virtual Contexts of ADL

Activity: Tangible Context Activity: Virtual Context Brick/mortar banking, shopping Mobile banking, bitcoin, shopping Meetings, scheduling Videoconferences, digital schedules Checkers/chess Online or VR checkers/chess Travel VR travel experience Brick/mortar education Asynchronous online education Religious services, running club Online religious services, social networking services

* Whether a person engages through a tangible or virtual context with an activity, they still require physical interaction and an interface/tool/technology (Until we become telepathic and telekinetic…) Reality – Virtuality Continuum

5 Reality – Virtual Reality

• Reality - environments consisting solely of real objects • constrained by the laws of physics • real-world scene viewed in-person or displayed on a monitor or head mounted display (HMD) • Virtual Reality (VR) – synthetic environments consisting solely of computer-generated virtual objects • may simulate real or fictional environments • may or may not follow laws of real-world physics • digital scene viewed on a monitor or HMD

6 Mixed Realities

• Augmented Reality - real environment viewed with a portion of VR added • can be layered or anchored/scalable to the real environment • Augmented Virtuality – VR viewed with a portion of the real environment added • can be video or texture mapped • can be completely or partially immersive

7 Virtual Reality Concepts

8 VR Concepts

• Experiential vs. User Controlled • Virtual Environments • Non-immersive • Video games, internet computer games, Wii games, Xbox Kinect games, Robotics/exoskeletons • Mixed • Augmented Reality; ie. Pokemon Go, Hololens, Cave • Augmented Virtuality; ie. PlayStation Eyetoy, IREX VR system • Immersive • Heads up displays with/without tracked body

9 VR Concepts

10 Non-Immersive VR?

11 VR Concepts

• Experiential vs. User Controlled • Virtual Environments • Non-immersive • Video games, internet computer games, Wii games, Xbox Kinect games, Robotics/exoskeletons • Mixed • Augmented Reality; ie. Pokemon Go, Hololens, CAVE • Augmented Virtuality; ie. PlayStation Eyetoy, IREX VR system • Immersive • Heads up displays with/without tracked body

12 Mixed Reality AR

13 Mixed Reality AV

14 VR Concepts

15 Evaluating and Understanding the Virtual Reality Evidence

16 VR Evidence: Stroke

• AHA Stroke Rehabilitation Guidelines: • It is reasonable to provide repeated VR to improve neglect symptoms after stroke. • It is reasonable to consider VR as a method for delivering upper extremity movement practice. • The use of VR to improve visual-spatial/perceptual functioning may be considered. • Customizing VR rehabilitation tasks according to the clinical needs and capacities of patients is important (Aminov, Rogers, Middleton, Caeyenberghs, & Wilson, 2018)

17 VR Evidence: Stroke

• May be beneficial in improving upper limb function and ADL function when used as an adjunct to usual care or when compared with the same dose of conventional therapy. (Laver et al., 2017) • VR rehabilitation moderately improves outcomes compared to conventional therapy (Lohse et al., 2014)

18 VR Evidence: Stroke

• Meta-analyses and systematic reviews suggest adjunct treatment with IVR provides • engaging, motivating, task-oriented and salient experiences • the requisite use, repetition and intensity of training for skill acquisition and performance. • immediate and longer-term improvements in motor function and the performance of cognitive and motor activities following stroke. (Aminov, Rogers, Middleton, Caeyenberghs, & Wilson, 2018)

19 VR Evidence: Limb Loss

• Quantitative or qualitative Improvement noted with VR and AR treatment for phantom limb pain (Dunn et al., 2017) • VR rehabilitation with a bimanual coordination task • encourages patient's motivation, multimodal sensorimotor re‐integration of a phantom limb and improves pain (Osumi M. et al., 2016)

20 VR Evidence: Burn Care

• VR significantly reduces pain, anxiety and stress during dressing changes and therapy (Scapin et al., 2018)

21 VR Evidence: Exertion

• Measurement of cardiovascular conditioning with IVR demonstrates increased engagement with a lower perception of exertion compared to actual exertion while maintaining comparable exertion activity levels such as walking, running and dancing. (Yoo, Ackad, Heywood, & Kay, 2017)

22 VR Evidence: Cognition Eval

• Exploratory research demonstrates the use of IVR in the evaluation and treatment of cognitive and spatial impairment with early evidence suggesting the convergent validity of an IVR cognitive assessment with traditional neuropsychological measures. (Davison, Deeprose, & Terbeck, 2018)

23 Research Reality: Considerations/Limitations

• Need to standardize the definition of VR • Used as part of a comprehensive rehabilitation program appears reasonable, taking into account the patient’s goals, abilities, and preferences • Significant heterogeneity and small study sizes limit the power of the conclusions • Not clear yet which characteristics of VR are most important

24 Research Reality: Considerations/Limitations

• Unknown whether effects are sustained • Adverse affects may vary depending on the characteristics of the person, the VR hardware and software, and the task • It is necessary to emphasize the importance of methodological rigor in clinical studies to improve the evidence of VR use

25 Research Reality: Considerations/Limitations

• Recommendations promoting the use of VR were mostly based on • non-immersive VR and MR environments inclucing 2D and 3D interactive video or motion capture • keyboard or mouse-based interfaces • console game systems such as the Xbox Kinect and Wii. • Recommendations can create confusion when therapists generalize treatment results between different types of VR, particularly to treatment with immersive VR

26 Assessing Virtual Reality Platforms & Activities

27 PlayStation4 VR

• Pros • Easy and quick setup and portability • Works well for trunk balance / control • Headset tracking / neck ROM • Comfortable to wear / minimal face weight • Standing or seated gaming • Cons • Limited motion control, requires hand function for basic controls • Controller tracking is not as robust • Limited room scale / ability to move around room

28 Oculus Rift

• Pros • Easy setup, but a little time needed • Easy portability • Works well for trunk balance / control • Adaptable headset tracking / neck ROM • Good UE (or LE) motion tracking in standing / sitting • Cons • Requires hand function for basic controls • Limited room scale / ability to move around room • Some weight on face • Requires powerful computer / graphics card

29 Windows Mixed Reality

• Pros • Easy / fast setup and portability • Inside-out tracking / No external cameras needed • Works well for trunk balance/control • Headset tracking/neck ROM • Good UE motion tracking in standing or sitting • Room scale / Capability to move throughout room • Lower computer and graphic card requirements • Cons • Requires hand function for basic controls • Limited 3600 tracking

30 Linking VR to Goals

• Match type of VR to client-specific goals/interests. • The goal is more important than the tool • Use activity analysis (“Research”) to understand specific game’s accessibility and gradability • “Research” will allow clinician to use creativity and clinical reasoning to monitor/adjust equipment and software to facilitate progress toward goals

31 Linking VR to Goals

• “Research” will also allow clinician to; • anticipate, accommodate, and manipulate client responses to the mismatch of physics between reality and virtuality • Incorporate treatment interventions or strategies into the activity • bilateral training • visual/sensory scanning • cognitive cueing • strength / endurance / balance

32 Integrating Virtual Reality in Practice: Video Case Presentations

33 Lower Body Dressing With C6 Asia A SCI: Trunk Control

34 Lower Body Dressing With C6 Asia A SCI: Trunk Control

35 Lower Body Dressing With C6 Asia A SCI: Trunk Control

36 Lower Body Dressing With C6 Asia A SCI: Trunk Control

37 Lower Body Dressing With C6 Asia A SCI: Trunk Control

38 Lower Body Dressing With C6 Asia A SCI: Collar Off

39 Scanning Strategies: Mild Left Neglect

40 Scanning Strategies: Mild Left Neglect

41 Scanning Strategies: Mild Left Neglect

42 Standing Self Care/Mobility LE Weakness/Proprioceptive Awareness L1 ASIA D SCI

43 Standing Self Care/Mobility LE Weakness/Proprioceptive Awareness L1 ASIA D SCI

44 Standing Self Care/Mobility LE Weakness/Proprioceptive Awareness L1 ASIA D SCI

45 Standing Self Care/Mobility LE Weakness/Proprioceptive Awareness L1 ASIA D SCI

Function at Discharge 46 Summary

• Virtual reality is increasingly being used in clinics and in research to address many client factors and performance skills. • It facilitates treatment that can foster an ecologically valid context, in a safe and controlled environment, to improve cognitive, perceptual and motor performance. • The evidence suggests that virtual reality treatments should be used in addition to therapy occurring in a real environment vs. a stand- alone treatment.

47 References:

• Aminov, A., Rogers, J. M., Middleton, S., Caeyenberghs, K., & Wilson, P. H. (2018). What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta- analysis of upper-limb and cognitive outcomes. Journal of Neuroengineering and Rehabilitation, 15(1), 29. https://doi.org/10.1186/s12984-018-0370-2 • Davison, S. M. C., Deeprose, C., & Terbeck, S. (2018). A comparison of immersive virtual reality with traditional neuropsychological measures in the assessment of executive functions. Acta Neuropsychiatrica, 30(2), 79–89. https://doi.org/10.1017/neu.2017.14 • Dunn, J., Yeo, E., Moghaddampour, P., Chau, B., & Humbert, S. (2017). Virtual and augmented reality in the treatment of phantom limb pain: A literature review. NeuroRehabilitation, 40(4), 595–601. https://doi.org/10.3233/NRE-171447

48 • Laver, K. E., Lange, B., George, S., Deutsch, J. E., Saposnik, G., & Crotty, M. (2017). Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD008349.pub4 • Lohse, K. R., Hilderman, C. G. E., Cheung, K. L., Tatla, S., & Loos, H. F. M. V. der. (2014). Virtual Reality Therapy for Adults Post-Stroke: A Systematic Review and Meta-Analysis Exploring Virtual Environments and Commercial Games in Therapy. PLOS ONE, 9(3), e93318. https://doi.org/10.1371/journal.pone.0093318 • Osumi M., Ichinose A., Sumitani M., Wake N., Sano Y., Yozu A., … Morioka S. (2016). Restoring movement representation and alleviating phantom limb pain through short‐term neurorehabilitation with a virtual reality system. European Journal of Pain, 21(1), 140–147. https://doi.org/10.1002/ejp.910

49 • Scapin, S., Echevarría-Guanilo, M. E., Boeira Fuculo Junior, P. R., Gonçalves, N., Rocha, P. K., & Coimbra, R. (2018). Virtual Reality in the treatment of burn patients: A systematic review. Burns. https://doi.org/10.1016/j.burns.2017.11.002 • Winstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C… (2016). Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke, STR.0000000000000098. https://doi.org/10.1161/STR.0000000000000098 • Yoo, S., Ackad, C., Heywood, T., & Kay, J. (2017). Evaluating the Actual and Perceived Exertion Provided by Virtual Reality Games. In Proceedings of the 2017 CHI Conference Extended Abstracts on Human Factors in Computing Systems (pp. 3050–3057). New York, NY, USA: ACM. https://doi.org/10.1145/3027063.3053203